Reporting Guidelines for Clinical Laboratory Reports in Surgical Pathology

Archives of Pathology & Laboratory Medicine, Oct 2008 by Goldsmith, Jeffrey D, Siegal, Gene P, Suster, Saul, Wheeler, Thomas M, Brown, Richard W

Context.-The surgical pathology report (SPR) is an essential part of patient care because it documents the pathologic findings in tissues removed from patients for diagnostic or therapeutic reasons. Despite the importance of the SPR, exhaustive guidelines outlining the various elements of the SPR have not, to our knowledge, been published.

Objectives.-To outline recommendations delineating the required, preferred, and optional elements that should be included in the SPR. These guidelines, if implemented, will bring uniformity to the reporting of surgical pathology specimens.

Data Sources.-The Surgical Pathology Resource Committee of the College of American Pathologists compiled and prioritized the elements that have been included in various institutional SPRs. Additional data sources include the College of American Pathologists Laboratory Accreditation Program checklists and the recommendations of the Association of Directors of Anatomic and Surgical Pathology. Each element was assigned a priority of required, preferred, or optional. These priorities were discussed and consensus was reached. This report does not address issues of formatting or style substantively.

Conclusions.-These recommendations afford a framework for the creation of an SPR containing all of the components that are required or optimal for patient care.

(Arch Pathol Lab Med. 2008;132:1608-1616)

The surgical pathology report (SPR) is the final written product of the surgical pathology laboratory, and it contains critical information that drives patient care, especially in the oncologic setting. A variety of individuals, including physicians, nurses, statisticians, epidemiologists, support personnel, and patients, use the information contained in the SPR. Because of the variety of people who access the SPR and the importance of the information contained therein, the report must contain a minimal amount of standard content and must be presented in such a way as to efficiently and accurately convey its information.

The College of American Pathologists (CAP) has developed guidelines for the content of SPRs. Similar guidelines were developed in the past by the Association of Directors of Anatomic and Surgical Pathology (see http://www.adasp.org/papers/position/Standardization.htm, last accessed March 14, 2008); additionally, various organizations have called for report standardization.1 In this article, we have compiled an exhaustive list of elements to be included in the SPR. Some of these recommendations are contained in the CAP Laboratory Accreditation Program checklists (see http://www.cap.org, last accessed March 14, 2008). This article is meant to convey guiding principles regarding the elements that should be contained in the SPR. Additionally, this article serves to rank these elements by degree of importance.

A summary of the body of the recommendations is contained in Tables 1 through 10. These tables are organized by the various sections of a typical SPR. It is not the intent of this article to dictate the format of the report, which might include properties such as font, type size, and position of the various elements on the typed page, nor is it our intent to dictate that the various elements be located in the particular sections delineated in the tables. However, it is clear that a well-designed SPR more effectively conveys critical information to the reader.2 The location of the constituents within the SPR is ultimately at the discretion of its creators. The exception to this is text color, which should always be black because many methods of duplication (eg, copy machines, facsimile) do not reproduce nonblack colors well. It is our intent, however, to provide a standardized list of the content elements to be included in the various sections of the SPR so that all readers, be they certified coders, billing clerks, or paramedical or medical personnel, can be assured that all required information will be present in the SPR, regardless of the laboratory of origin.

The SPR is being generated with ever-increasing frequency in electronic format. These guidelines should be applied to the SPR, regardless of the mode in which it is published; however, certain elements, such as the subsequent-page header or footer (Table 2), might be eliminated if SPRs are generated in a purely electronic format. In the tables of this manuscript, some elements are not preceded by a symbol. These are deemed required elements that must be included in all reports. Other elements are considered preferred, as designated by the * symbol. The preferred entries are considered important to convey to the reader and should be included in some fashion, unless their inclusion is precluded by hospital policy or some other extenuating circumstance. A few of the elements are considered optional and are designated by a dagger ([dagger]).

The content that follows includes a detailed description of the SPR elements and the reasoning behind our decisions regarding the necessity of the various constituents.